Impella 5.5 Support to Bridge an 18.5 kg Pediatric Patient to Heart Transplantation

This article is part of CTSNet’s Guest Editor Series, Insights Into Pediatric Mechanical Circulatory Support. Congenital and pediatric surgeon Dr. Sandeep Sainathan invited accomplished pediatric surgeons from around the world to contribute clinical videos on the surgical aspects of pediatric mechanical circulatory support as a bridge to cardiac transplantation or recovery of cardiac function.    

The Impella 5.5 device was designed to provide short-term mechanical circulatory support (MCS) in adults. This report details the use of the Impella 5.5 to bridge the smallest reported child (18.5 kg) with the longest duration of support (105 days) to heart transplantation (HT). 
 
A 7-year-and-8-month-old child with a history of aortic annuloplasty, atrial septal defect (ASD), and ventricular septal defect (VSD) repair at one month of age was listed for a heart transplant due to end-stage dilated cardiomyopathy. While on the waitlist and receiving ionotropic support, the child’s clinical status deteriorated, leading to end-organ dysfunction. In addition to renal dysfunction, respiratory failure requiring mechanical ventilation, and arrhythmias, the decision was made to place a mechanical circulatory support device using the Impella 5.5. 
 
A pre-implant fitting study using advanced imaging was conducted. With a suprasternal incision, an 8 mm graft was sutured to the innominate artery. The graft was tunneled above the right clavicle, and the Impella 5.5 was deployed under echocardiographic guidance. The patient experienced a gradual recovery and began rehabilitation, with improvements in her symptoms and functional mobility. During her prolonged Impella support, there was minimal evidence of hemolysis or device malfunction. She required a blood transfusion for a gastrointestinal (GI) bleed related to stress ulcers. After 105 days of Impella support, a donor heart became available, and she was taken to the operating room for heart transplantation. The device was turned off, and the aorta was clamped and transected for device removal. The graft was shortened and closed, followed by a standard heart transplantation operation. Post-transplant recovery was uneventful. 
 
This case is unique, providing mechanical circulatory support (MCS) using the Impella 5.5 in the smallest reported child (18.5kg) with the longest reported support duration (105 days). The fitting study aided in planning, and the suprasternal approach provided adequate access to the innominate artery for graft insertion and Impella deployment. The prolonged support was achieved with minimal hemolysis, device malfunction, and excellent rehabilitation. The Impella 5.5 serves as an armamentarium for supporting children with end-stage heart failure listed for transplantation. 

Disclaimer

The information and views presented on CTSNet.org represent the views of the authors and contributors of the material and not of CTSNet. Please review our full disclaimer page here.